Interventions for child development based on the Touchpoints Model: scoping review

Objective: to map the characteristics of interventions to promote child development that used the Touchpoints Model. Method: this is a scoping review, guided by the recommendations of the JBI Reviewer’s Manual, carried out in nine databases, in the gray literature and in the reference list of the selected studies. The research question was “what are the characteristics of interventions with parents/caregivers and children to promote child development, from pregnancy to six years of age, based on the Touchpoints Model?”. Rayyan was used for the selection of studies and a standard form for data extraction. The analysis was carried out descriptively. Results: twelve publications were included in the review. Interventions were heterogeneous; concentrated in the period from pregnancy to three years of age; prioritized the dissemination of Touchpoints content according to age, and parenting aspects; most were performed by nurses, in Primary Health Care, and during home visits. Interventions were related to overall development, greater understanding of development and greater interaction with the child. Conclusion: studies have shown potential for favorable outcomes for child development and parenting. The variability of interventions made it difficult to map more effective characteristics.


Introduction
Early childhood is defined as the first six years of a child's life, and has been recognized as a strategic moment to provide opportunities for the child's biological, psychological, cognitive and social development (1) .The implementation of interventions to promote development in this period of life has been a national and international priority.The Nurturing Care strategy, launched by the World Health Organization (WHO) in 2018 as a set of global actions aimed at responsive care for children, points to child development (CD) as an important aspect to achieve the Sustainable Development Goals (SDG-2030) (2)(3) .
Interventions aimed at CD have expanded knowledge about developmental science, and need to be implemented in a multisectoral way and anchored in nurturing care.The home environment and childcare environments represent a powerful and immediate nurturing context for children to reach their full developmental potential (1) .
In this context, evidence demonstrates that parenting interventions are necessary to promote healthy CD, being able to improve parental knowledge, parenting practices and interactions between parents and children (4)(5)(6) .
Parenting interventions also demonstrate positive effects on children's cognitive, language, motor, socio-emotional and attachment development, results that are seen in low-, middle-and high-income countries (4) .
Programs focused on CD have improved child care, but there is a predominance of vertical interventions and family education, with scarce use of the theoretical framework to support them (7) .
A theoretical reference that has not yet been tested in the Brazilian reality and that aims at an intersectoral practice and with a focus on parental competence is the Touchpoints Model (TP).Created by Thomas Berry Brazelton, the TP Model is an approach to child development that is grounded in cultural sensitivity, reflective practice, and systems theory (8) .This model establishes a way of caring for families by understanding the development and supporting family relationships.By adopting a new concept of child development -as nonlinear, characterized by regressions, spurts and pauses -it understands that child behavior regressions can generate disorganization in the family system and be disruptive (9) .The model addresses 15 Touchpoints, from prenatal care to 6 years old, which are periods of regression and disorganization of the child who is learning a new skill (9) .In this approach, the family needs to be supported in a web of intersectoral relationships through an articulated work between health service professionals, educational and social sectors.The model seeks a paradigm shift to respond to the needs of children and their families through an anticipatory, preventive and collaborative orientation based on the experiential learning of parents through observation of their children's behavior, and is based on eight principles, which are guides for professional work (9) .
In the field of interventions aimed at child development with parental emphasis, there is limited evidence, so there is a need to evaluate existing interventions, as well as to develop new interventions to optimize the offer to families (10) .
With the need to explore this model and raise aspects

Method Study type
This is a scoping review.This study was developed and structured according to the recommendations the JBI (11) and the checklist Preferred Reporting Items for
For the development of the study, the following methodological steps were taken: formulation of the research question, using the Acronym PCC-Population, Concept and Context; definition of inclusion and exclusion criteria, using the PCC and defining the types of studies and sources; elaboration of a search strategy; identification of databases; search and selection of studies; data extraction and analysis; and construction of the report (11) .

Setting
The review was carried out in eight databases: Public Interventions were defined as activities carried out as planned, with the aim of producing a positive effect (4,13) , whether policies, programs or individual practices.The gestation period until the child`s 6 years of age has been the focus of programs and policies in Brazil (14) and is the period covered by the TP Model (9) .Studies that did not include the population, concept and context of interest, or that did not report the application of an intervention, such as editorials, letters to the editor and opinion articles, were excluded; in addition to incomplete studies that were not located in full after trying to contact the Brazelton Touchpoints Center and the Brazelton/Gomes-Pedro Foundation.Duplicate documents were considered only once.
There was no time, geographic or language restriction.

Study variables
The study variables were those recommended by the JBI (11) : authors; country; year of publication; kind of study; goal; population; context in which the interventions were carried out; plus those recommended by the Template for Intervention Description and Replication (TIDier) (15) : theoretical framework used; professional responsible for the intervention; intervention content; materials and strategies used; delivery mode; volume (number of times, duration and period); intervention results/effects.

Instruments used for data collection
The standard form used for data extraction was prepared in Microsoft Word ® software based on the items that must compose the interventions according to the TIDieR (15) .whether strategies were used to maintain and/or improve the intervention).Fidelity refers to the degree to which an intervention was delivered and received by participants as planned (15) .The form was completed by two reviewers and a consensus was reached between the collected information and the grouping of information in a single table.

Data collection
One of the reviewers was trained by JBI Brazil to conduct reviews and shared the guidelines learned with the other reviewer before starting the study.

Data processing and analysis
The data extraction form prepared in Microsoft Word ® software allowed the synthesis, interpretation of data and numerical analysis of the distribution of studies, being represented by a narrative summary of the results, which were related to the research objective and question.For the description of the review, PRISMA-

Ethical aspects
There was no need to submit the study to the Research Ethics Committee.

Results
A total of 251 studies were identified, excluding 46 duplicates via Rayyan ® , leaving 205 studies.A total of 190 studies were excluded by reading the title and abstract, and another three exclusion during the full-texts reading, two of them for not having been located and one for not contemplating the study population.Thus, 12 studies were included in this review: five scientific articles, one book chapter, three dissertations, and three theses (Figure 2).
In three of the included studies, the intervention has not yet been applied (16)(17)(18) , therefore, there are no results/ effects described.

United States. 2001 Pilot study
To test an intervention that aims to increase parental self-confidence among pregnant women and low-income teenage mothers.

United States. 2009 Pilot, quasiexperimental study
To strength anticipatory guidelines for promoting child development in Latino and African-American families in a Primary Care Center; strengthen the adequacy of family needs and resources, increase families' knowledge about educational practices and promote resilience; promote immunization and child development.

Randomized controlled trial
To verify whether short-term interventions with high-risk pregnant women can improve parental attitudes and home environments.

Prospective and retrospective randomized study
To verify whether a TP* model-based approach to public health nurse home visits is associated with better six-month outcomes for high-risk dyads than a traditional nurse home visit model or no home visit.

Randomized controlled trial
To analyze the effect of the health education program for mothers (PEPDI -Parental Empowerment Program for Child Development), on child development, as well as on maternal characteristics.
Castelão ASD (25) Portugal.2013 Action-research Study the implementation of a Touchpoints program to promote a relationship of trust and partnership between the teacher and the parents.

Action-research
To study the impact of Touchpoints training on the educator's representations and in the educator-parent relationship, and to verify how alterations in the educator's representations and in the relationship established with the parents affect the child's development and the quality of the educational context.

Quasi-experimental longitudinal study
To evaluate the impact of clinical nursing intervention using the TP* model on mother-child interactive behavior and child development between the first and second year of life.
Martins PAC (17) Portugal.2017 Pilot study † To promote child development and parenting in the first year of life.
DiCero KE (18) United States.2018  Pilot study † To reduce or prevent the involvement of families in the Massachusetts Department of Children and Families, increase the mother's positive attachment interactions with her baby; document a typical developmental trajectory for babies in the program; achieve positive connections of adolescent mothers with the therapist.

Randomized clinical trial protocol †
To evaluate the effect of a parental intervention based on the Touchpoints model on the sense of parental competence of parents of children younger than 18 months, in comparison with usual care and its relationship with other dimensions: mental health and parental well-being (stress, depression, anxiety, psychological experience of pregnancy, attachment, quality of life), child development (physical/sensory-motor, psychosocial) and family well-being (family and couple functioning).

Longitudinal, quasiexperimental study
To determine whether mothers who receive HUG Your Baby prenatal education do better than a control group with regard to postpartum depression and related factors.The nurse was the professional who performed the intervention in six studies (19)(20)(21)(22)(23)26) , in one of them together with researchers (19) and, in another, with physicians (21) ; will also be the professional responsible for two of the interventions not yet carried out (16)(17) . Theother responsible professionals were physicians (16)(17)21) , researchers (16,19,27) , educators (20,(24)(25) and social worker (20) .
The period of the intervention, duration and frequency differed between studies.Two of the studies carried out the intervention in person, in groups (19,27) , six performed face-to-face and individually (21)(22)(23)(24)(25)(26) , and one study carried out in a hybrid format, with face-to-face meetings and telephone contact for follow-up (20) .Of the interventions not applied, one will be in a group (18) and two will occur individually (17)(18) .

The main contents worked on in the interventions
were the experience of the parents during pregnancy and labor (16)(17)19,(21)(22)24,26) ; the change in the relationship with the family after the baby's birth; the difficulty of fatherhood; the child's temperament (19) ; strengthening the parent-health-professional relationship with a focus on child development, parent-child interaction, appropriate behaviors for the child's age; increased knowledge of families and use of community resources (20)(21)23,27) ; strategies for developing parental sensitivity and understanding of child development (17,(20)(21) ; anticipatory care adjusted to key ages based on the Touchpoints Model (16)(17)(18)(19)(20)(21)23) ; child's developmental skills (21,26) ; situations predictable to occur in relation to development, challenges and parenting concerns (18,23) .
Changes in the intervention during the research were described in only one study, with the inclusion of night classes for spouses and boyfriends at the request of mothers (19) .Two studies offered incentives for participation, such as toys and books, calendars, certificates and gifts from grocery stores (20) and $50 shopping vouchers (21) .
Adherence to the intervention was described in only one study, which did not describe the strategies used to maintain or improve adherence (19) ..

Touchpoints Model
The family needs inventory was used for them to indicate topics they would like the team to evaluate and discuss, such as: growth and development, playing, how to deal with concerns about CD † , aspects of social, family and financial support.
The IG ‡ families received HV † † with the TP* model approach, and the CG § received visits at the same age as the children, without using the TP* approach.Intervention not yet performed

Nurses of Primary
Three family doctors and one nurse per unit.216 parents (from pregnancy to 18 months of the baby) (16) .

Touchpoints Model
For families, 28 leaflets on anticipatory care will be used for each Touchpoint, addressing needs and fears.
For the training of professionals, slides, videos and leaflets will be used.
IG The intervention lasted approximately two hours.Periodicity was not described.
There were significant differences between the two groups with regard to: knowledge of the infant's behavior (baseline, one month and three months) (p ¶ < 0.01), Karitane Parental Confidence Scale (KPCS) scores at one month (p ¶ <0.01).The intervention demonstrated a positive impact on preventing postpartum depression, increasing parental confidence, reducing maternal stress, and increasing knowledge about the baby's attachment Vicente JB, Pegorin TC, Santos ALO, Veríssimo MLOR.

Discussion
Intervention programs are considered essential for understanding the behavior and needs of children by parents, promoting parenting competence, learning about child development and greater stimulation of children (4,6,(28)(29)(30) .Thus, this review mapped the characteristics and effects of interventions that used the Touchpoints Model with emphasis on the essential components described in TIDieR (15) .By mapping the complete description of the interventions, it becomes possible to identify characteristics that provide the achievement of favorable results, to implement them, replicate them, or develop new studies based on the findings.
There was a concentration of production in the United States, possibly because it is the country in which the model was created, and because of the existence of the Brazelton Touchpoints Center (BTC), which promotes training for professionals (9) , and in Portugal, for hosting a BTC partner foundation, the Brazelton/Gomes Pedro Foundation, which works to disseminate a clinical intervention paradigm based on the model (31) .
The first reflection about the studies is about the variability of interventions with regard to content, strategies and volume.Figure 4 shows that there is repetition of only one intervention (25)(26) .In the others, although some elements are recurrent, the complete design of each one is always new.This occurs because they knowledge about CD (28)(29) , support the construction of the parental role, and understand the reality of each assisted family, for physical health care and to promote a safe environment (32) .Thus, although the Touchpoints model in the early years (7) , and scientific evidence shows that home visits offer favorable conditions for working on early childhood issues and needs, with better development of children in cognitive, behavioral and socio-emotional dimensions (29,33) .
As for the various resources used in the interventions, such as leaflets, videos, guides/scripts, handouts, books and toys, they are similar to those usually used in research on educational interventions (4,7,30) .However, the absence of information about the intervention material is remarkable, given that it was available in only two studies, one that shared the folder used (27) , and another that provided the Uniform Resource Locator (URL) of the videos and songs (18) .This makes it difficult to objectively appreciate such materials and even relate the results to their quality.
Still, it does not allow interventions to be replicated in other contexts for new evaluations.
The main contents explored in the interventions were the parents' experience during pregnancy and labor; parent-child interaction; child's behaviors as their language; understanding of child development; anticipatory care for every age; parenting challenges and concerns.These contents are in line with the main topics to be addressed from the prenatal Touchpoint (9) , showing fidelity to this aspect of the model.However, as previously mentioned, it was not possible to access the contents of the interventions in a complete way, which makes it impossible to measure whether the interventions follow all the principles and assumptions, guaranteeing this fidelity.
Although the volume of the intervention differed between the studies, ranging from six weeks to 18 months, and, in most cases, there is no description of the duration of each meeting, nor the fidelity of the intervention, that is, whether it was delivered as planned or recommended by the model (15) , all had positive results.This shows that the effects on parental behaviors, knowledge and attitudes can be quickly visible when using an approach that values disorganization and vulnerability as an opportunity to support and validate parenting practices, rather than treating them as weaknesses or harmed behaviors.
Review studies have shown good effectiveness of interventions focused on parenting to promote development (4,34) , although another review points out the infeasibility of performing meta-analyses or metasyntheses of studies of this nature, or understanding why the interventions work, due to the variability of the interventions tested (10) .Adherence was mentioned in only one study (19) , which did not detail the strategies used to maintain or improve it.
Fragility is observed in the description of these central constructs of the interventions, which was also identified in a systematic review and meta-analysis that evaluated the effectiveness of parental interventions (4) .
This lack of transparency makes it difficult to carry out interventions on a large scale, as it does not allow for the understanding of more or less successful interventions, and the dissemination of what worked or not, for whom and how (13) .

The use of current technologies in interventions was
not identified, such as the internet (message sending applications, videoconferences, social media), and only one of them was carried out in a hybrid format, with faceto-face meetings and telephone follow-up (20) ; this may be related to the fact that most studies were conducted more than 10 years ago.Currently, technologies are part of everyday life for families and enhance communication between health professionals and parents, facilitating and favoring different ways of delivering interventions, although there is the challenge of disparities in access to these technologies (7) .
The interventions did not explore the TP Model in depth, did not describe how it was used in its design, and which principles were applied.However, in the description of contents and effects, three principles were identified in most studies: "use the child's behavior as their language, focus on the parent/child relationship and look for opportunities to support parental dominance" (9) .

All interventions carried out qualification/training
in the TP model for the professionals who applied the interventions with the target audience, but there is no information on how or if the consistency of professionals in working with families was verified.
In the present review, the strategies used in the of parents (9) .
The main outcomes of the interventions were better global CD results, greater understanding of CD and the child's behavior as its language, improved sense of parental competence and greater maternal sensitivity, greater interaction, responsiveness and time with the child, greater use of toys and learning materials, resembling the results of other parenting interventions (4,6,(28)(29)(30)34) .
It Even so, such results justify further studies for the use of the model in public policies in Early Childhood, to support practices that promote CD, with emphasis on the socio-emotional, as it is innovative, when considering Touchpoints instead of just developmental milestones, and when acting from the perspective of family-child and professional-family interactions (9) .
Although no time or language cut-off was carried out, the limitations of the study refer to the small number of publications located, mainly in the last five years, that contribute to the proposition of new interventions, this study aimed to map the characteristics of interventions for the promotion of child development that used the TP Model, due to its potential to foster a care practice advanced in different care contexts for Brazilian children and families.No review on the subject was found in a previous search in the JBI database, the International Prospective Register of Systematic Reviews (Prospero), Cochrane Database of Systematic Reviews and the Open Science Framework (OSF) platform.
MedLars (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Resources Information Center (ERIC), Psychological Information Database (PsycINFO), Latin American and Caribbean Literature in Health Sciences (LILACS), Database in Nursing (BDENF), Excerpta Medica Database (EMBASE), Selection criteria The review question was: "what are the characteristics of interventions with parents/caregivers and children to promote child development, from pregnancy to six years of age, based on the Touchpoints Model?"The PCC Acronym (11) was defined as: P-Parents/ caregivers and children; C-Interventions to promote child development that use the Touchpoints Model; C-All contexts of child care.Studies that responded to the research objective and the review question were included, reporting on an intervention aimed at promoting child development, from pregnancy to the child's six years of age, and based on the Touchpoints Model.It could be an intervention already applied, or its protocol/design, and in any context of care -health, education, social assistance or home services.
improve the complete description of interventions to allow their replicability.It contemplates the following items of an intervention: why (theory); what and which (materials and strategies); who did it (professional); how (in person, via internet or telephone, in groups or individually); where (place where it occurred); when and how much (volume -number of times and what period of time); how well (whether adherence or fidelity was assessed, how and by whom; Searches in the databases were carried out on October 12, 2022 through registration in the Portal de Periódicos (Journals Portal) of the Coordination for the Improvement of Higher Education Personnel (CAPES), via the Federated Academic Community (CAFe).Thesis databases and institutional websites were accessed on the aforementioned date via Google search engine.The definition of the databases and the search strategy was carried out with the help of a librarian.The selected descriptors were combined according to the characteristics of each database and search engine.The selected databases and respective search strategies are shown in Figure 1.

Figure 2 -
Figure 2 -Flowchart of the article selection process for the adapted scoping review of the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).São Paulo, SP, Brazil, 2023

*Figure 3 -
Figure 3 -Identification of studies according to author, country, year of publication, type of study and objective.São Paulo, SP, Brazil, 2023

*Figure 4 -
Figure 4 -Characterization of interventions.São Paulo, SP, Brazil, 2023 are designed according to research objectives, which focus on specific aspects of expected results.It is observed, therefore, that there was no particular intervention tested in multiple aspects, even though all were based on the Touchpoints model.The discussion on the constituent elements of the interventions, below, sheds light on aspects that can contribute to the understanding of such interventions, based on common points and variability.The predominance of nurses as responsible for applying most interventions is in line with this professional's profile.Studies have highlighted the essential role of nurses in empowering parents through strategies that allow exploring parenting, incorporating of interventions individually, to the detriment of group interventions, shows a possible preference of researchers for the individual approach.This contradicts current research that points to the widespread use of group strategies, as they promote learning among peers through the exchange of knowledge and sharing of experiences, interventions were directed towards changing the knowledge, behavior and attitude of the parents in order to understand the development and behavior of their children.Research identified the paradigm shift proposed by the TP model, focused on anticipatory guidance and collaborative practice based on the experiential learning was possible to examine the nature and extent of the interventions that used the TP model, and, although the positive effect is evidenced in all studies, the weakness in the description of the volume does not allow relating them to the duration of the intervention, and the heterogeneity of the interventions limits the comparison of these results.As the main contributions of the study, one can consider the positive outcomes present in all investigations, in addition to highlighting the importance that reports of intervention studies contemplate in a more comprehensive way the description of the intervention itself.Although the positive outcomes may justify the recommendation to test interventions based on the TP model in the Unified Health System (SUS), it is only possible to consider that they should include the common characteristics described in the studies, such as the anticipatory care approach, guidance on child development and parenting, carried out by nurses and in PHC.However, the lack of details on the interventions does not allow us to state that such positive outcomes, even in short-term interventions, are related to the nonprescriptive approach and other characteristics of the professional-family relationship that differentiate the TP model from traditional interventions.
with a predominance of studies in the grey literature to the detriment of the nine databases, and the exclusion of two searches due to not being located.Still, the incomplete description of the key components of the interventions makes it difficult to understand the results and compare them.Conclusion Interventions focused on the period from pregnancy to three years of age, and most were carried out by nurses in Primary Care and in the HV, prioritizing the dissemination of Touchpoints content according to age, Vicente JB, Pegorin TC, Santos ALO, Veríssimo MLOR.and aspects of parenting.The studies showed potential for favorable results for child development and parenting.The variability of interventions made it difficult to map the most effective characteristics.The mapping of interventions that used the TP model responds to the need in the field of parental interventions and explores a model that can be used and better characterized in new interventions to compose public policies in Early Childhood, given the positive results observed so far.